Gastroenterology Coding Alert

Every practice wants to submit clean E/M claims, but with the various regulations and requirements you must follow, sometimes you might not know where to look for issues.

For instance, she has seen EHRs that have the review of systems (ROS) pre-templated to be complete, with 10 or more systems addressed for all patients. However, in some documentation, the physician will fail to delete that pre-templated response and will indicate that something in the ROS was actually addressed differently.

“I once did a chart review where the medical record had an ROS response under the musculoskeletal section that said ‘patient denies joint/muscle pain,’ but in the history of present illness, the provider had written ‘patient complains of knee pain.’ So that clearly indicated the provider either did not personally take the ROS or didn’t review the documentation in the patient’s chart and signed off on a contradictory medical record,” she said. “In this type of situation, as an auditor, I have to question the validity of the record. I’d hesitate to credit that provider with a complete ROS when they clearly didn’t review at least part of the ROS.”

When it comes to inpatient encounters, Clark often sees issues that stem from lack of either the history or exam component that support the codes billed. “For example, a 99222 or a 99223 (Initial hospital care, per day…) both require a comprehensive or complete history and exam, and in many cases, I’ll identify missing elements. I frequently see family history missing and commonly see a lack of either a complete eight organ system or comprehensive single organ system exam,” she notes.

2. Write in Your Code Book to Remember the Regs

When it comes to coding office visits based on time, many coders face confusion about how to tally and document the time to select the right code, says Lynn C. Schoeler, CPC, COC, CPC-I of L S Coding & Education in Tucson, Arizona. As you may be aware, when coding office visits based on time, you must document the total time spent with the patient and demonstrate that more than 50 percent of the face-to-face time the physician spent with the patient/and or family consisted of counseling/coordination of care. In addition, you must provide a description of the counseling/care coordination.

What trips up many coders is that you should select a code based on the total minutes you spent with the patient, not just based on the time spent counseling them. “The last page of the E/M guidelines has this information, and you really want to review it carefully, even if you think you know the requirements by heart,” Schoeler says. “So if you’ve spent an hour with a new patient and you talk to them for 30 minutes of counseling, you can bill it based on the total time spent which would allow you to report 99205 (Office or other outpatient visit for the evaluation and management of a new patient … Typically, 60 minutes are spent face-to-face with the patient and/or family).”

If you had coded the visit based on just the time counseling the patient, you’d have reported 99203 (… Typically, 30 minutes are spent face-to-face with the patient and/or family). Because 99205 pays about $102 more than 99203, that’s an expensive mistake to make.

In addition, Schoeler adds, you should always be reading the notes regarding the time spent, because in some cases, if you’re only choosing codes based on the history, exam, and medical decision making (MDM), you might shortchange yourself, since the time spent might allow you to report a higher code.

“Train the providers to document total time spent and then how much was in counseling, and what they discussed,” she notes. Something like “I spoke to the patient at length about dietary changes that are important to follow due to her GERD, total time spent was 38 minutes, 20 minutes of which was counseling,” then you can justify coding based on time.

If you’re rusty on the time-based coding rules, don’t forget to read the E/M guidelines in your code book, Schoeler advises. “A lot of people skip over the introductory notes in CPT^® and go straight to the code descriptions, but you shouldn’t. The first thing I teach coders is to write directly in the CPT^® book.”

For instance, she advises, if a code is on page 25 but the regulations for reporting it are on page 23, coders should put “p 23 paragraph 2” next to the code so they know where to find the regulations. Every year when a new code book comes out, she suggests going through it and marking it up, so you don’t miss any important guidelines. You should also check Medicare documentation guidelines to identify any discrepancies with CPT^®, and you can document those in your code book as well.

3. Don’t Forget Remote Evaluation Services

Some physicians could be losing money on their visits by not recording enough documentation to justify reporting telehealth codes appropriately. “I see a lot of telehealth visits either billed but not documented appropriately, or not billed due to concerns of inappropriate documentation,” Clark said. “In 2018, CMS started to expand reimbursement for remote services — some services are simply E/Ms, but also covered are phone calls, audio visual interactions, and online interactions. With the expansion and the current leniency/ flexibilities that most carriers are allowing, I’d like to see practices open remote services to include more frequent patient encounters.”

She recommends that practices review remote patient monitoring services, which benefit some specialties more than others and allow for things like remote blood pressure or continuous glucose monitoring. “It benefits the patient; we’ve seen great patient satisfaction from it, and it helps ensure that patients stay with the practice rather than going to an urgent care for issues that can be addressed via remote services,” Clark notes. In addition, there are state parity laws in 42 states plus Washington, DC, which provide reimbursement of these services.

You can report these services using codes in the ranges 99453-99454 (Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial …) and 99457-99458 (Remote physiologic monitoring treatment management services, clinical staff/ physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month …), in addition to code 99091 (Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days).

Note that remote glucose monitoring is reported with CPT^® codes 95249-95250 (Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours…), Clark adds.